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Tuesday, September 17, 2013

The US Health Disadvantage

Mobilization of an unprecedented kind is now necessary in the United States. It requires a campaign to remove the public veil
of ignorance about the evidence.

So states the public health Policy Forum in the Aug 30 issue of Science
("Confronting the Sorry State of U.S. Health," Bayer et al.*), which
raises some important questions about health and sickness in the United
States. The authors are commenting on a recent report
published by the U.S. National Research Council and Institute of
Medicine, "US Health in International Perspective: Shorter Lives, Poorer
Health," (Jan, 2013) which asks why the US is among the richest nations
in the world, and yet the health of its people is far down the list.
The report is the outcome of 18 months of work by a panel charged with
exploring the problem and identifying causes and solutions.

The
panel compared health outcomes of Americans with those of 16 other
wealthy countries. They found that Americans have had a shorter life
expectancy than people in the comparable countries for many years, and
that the differential is growing, especially for women. The health
disadvantage affects everyone up to age 75, it's worse among poorer
Americans but exists even in the wealthy, and includes multiple
diseases, risk factors and injuries.

It's worth quoting the panel's findings in detail.

1.
Adverse birth outcomes: For decades, the United States has experienced
the highest infant mortality rate of high-income countries and also
ranks poorly on other birth outcomes, such as low birth weight. American
children are less likely to live to age 5 than children in other
high-income countries.

2. Injuries and homicides: Deaths from motor vehicle crashes, nontransportation-
related
injuries, and violence occur at much higher rates in the United States
than in other countries and are a leading cause of death in children,
adolescents, and young adults. Since the 1950s, U.S. adolescents and
young adults have died at higher rates
from traffic accidents and homicide than their counterparts in other countries.

3.
Adolescent pregnancy and sexually transmitted infections: Since the
1990s, among high-income countries, U.S. adolescents have had the
highest rate of pregnancies and are more likely to acquire sexually
transmitted infections.

4.
HIV and AIDS: The United States has the second highest prevalence of HIV
infection among the 17 peer countries and the highest incidence of
AIDS.

5. Drug-related
mortality: Americans lose more years of life to alcohol and other drugs
than people in peer countries, even when deaths from drunk driving are
excluded.

6. Obesity and diabetes: For decades, the
United States has had the highest obesity rate among high-income
countries. High prevalence rates for obesity are seen in U.S. children
and in every age group thereafter. From age 20 onward, U.S. adults have
among the highest prevalence rates of diabetes (and high plasma glucose
levels) among peer countries.

7.
Heart disease: The U.S. death rate from ischemic heart disease is the
second highest among the 17 peer countries. Americans reach age 50 with a
less favorable cardiovascular risk profile than their peers in Europe,
and adults over age 50 are more likely to develop and die from
cardiovascular disease than are older adults in other
high-income countries.

8.
Chronic lung disease: Lung disease is more prevalent and associated
with higher mortality in the United States than in the United Kingdom
and other European countries.

9.
Disability: Older U.S. adults report a higher prevalence of arthritis
and activity limitations than their counterparts in the United Kingdom,
other European countries, and Japan.

It's not all
bad -- if an American reaches 75, s/he has a higher survival rate
thereafter; the US has higher cancer screening and survival rates, blood
pressure and cholesterol are better controlled, we're more likely to
survive a stroke, we smoke less and our average household income is
higher, suicide rates aren't higher than comparison countries (faint
praise, that), and the health of recent immigrants is better than that
of people born here. Otherwise, and even though health care spending per
capita is much higher in the US than the comparison countries, health
outcomes here are significantly worse. Though, of course, we're ahead of
the curve in some respects, obesity rates e.g., with other countries
fast catching up.

So, why the dismal picture in the
US? The panel considered this at great length (it's a 400 page
document). You'd think it might be because we have more people without
access to health care than other countries, but the disadvantage holds
even for those with access to care. We smoke and drink less, but eat
more. We have more accidents and have more guns. Our educational
attainment is lower than other countries, and poverty rates and income
inequality higher. and social mobility lower. And, the panel also
points out, a less effective social safety net. But, even those of us
with "healthy behaviors" are more likely to get sick, and have
accidents, than our counterparts in other wealthy countries.

So,
understanding what's behind the sorry state of health in this country
is not straightforward. Indeed, the panel seemed sorely tempted to
describe unhealthy social and environmental conditions in the US, and
ascribe our health conditions to the whole sorry mess.

Potential
explanations for the U.S. health disadvantage range from those factors
that are commonly understood to influence health (e.g., such health
behaviors as diet, physical inactivity, and smoking, or inadequate
access to physicians and high-quality medical care) to more “upstream”
social and environmental influences on health (e.g., income, education,
and the conditions in which people live and work). All of these factors,
in turn, may be shaped by broader national contexts and public policies
that might affect health and the determinants of health, and therefore
might explain why one advanced country enjoys better health than
another.

That's of course not very helpful in policy
terms because public health measures must be directed at something
specific, like cleaning dirty water or vaccinating against disease. The
situation reminds us of too many attempts to explain complex disease
with simple, enumerable factors -- for example, we dream of simple
genetic causes, but in fact it's multiple gene and environment
interactions. Here, the Affordable Care Act won't be the answer, nor
would gun control be, nor enforcing seat belt laws, nor banning
supersize drinks or increasing the availability of fresh fruits and
vegetables in poor neighborhoods. It's complicated. And surely a
combination of many factors, social and environmental.

The
panel recommends, though, more data collection, more refined analytic
methods and study design, and more research. They recommend focusing on
children and adolescents, because early life experiences and habits can
affect the whole life span. They also recommend that research should be
on the entire life course rather than more localized cause and
effect. But the study urges that the situation is so critical that
action must be taken while research is ongoing, and they provide a long list of actions they believe should be taken, from increasing the use of motorcycle helmets to increasing the availability of public transport to improving air and water quality and increasing the proportion of adolescents who don't use illegal drugs. More generally, they recommend:

(1) intensify efforts to pursue existing national health objectives that already target the specific areas in which the United States is lagging behind other high-income countries, (2) alert the public about the problem and stimulate a national discussion about inherent
tradeoffs in a range of actions to begin to match the achievements of other high-income nations, and (3) undertake analyses of policy options by studying the policies used by other high-income countries with better health outcomes and their adaptability to the United States.

But what kind of issue is this? A public health
issue? Public policy? Economic, educational? Here we come to a
fundamental question of causation. What, we might ask, causes AIDS? Is
it HIV? Needle sharing? Poverty? A confluence of factors at all
levels? Epidemiology has long struggled to take multi-level causation
into account, acknowledging the role of many different kinds of factors
including biological and social determinants (see Nancy Krieger's old
but seminal and still good 1994 paper
on this, "Epidemiology and the web of causation: has anyone seen the
spider?"), but once the web extends into social causes, the field of
public health is pretty much stymied when it comes to fixing things.
And throwing this into the political arena is a sure recipe for a lot of
grandstanding but not much else.

Is more research
really needed into why Americans are sicker than our counterparts in
other wealthy countries? No doubt it is a serious problem, and
very costly in both human and monetary terms. But of course the request
will be for more mega-scale, long-duration highly technological
studies--more grant money. You'd expect us to say that. But is the
plea for more funding a reflex or is it really the answer?

It does not
seem obviously so, except for the many small factors that would be
found. We know enough to know that the answer is going to be
complicated, and causal factors changeable. Indeed, we surely will be
found to be leading the pack in some measures, and other countries will
catch up. And, whether the fix is deemed to be personal behavior or
political, or a mix of many approaches, once we go beyond requiring
vaccines or seat belts, we are the master of none of them. And they're
always changing. Perhaps research money should be going into things like how to improve health education (that is, how to get people to do things they'd rather not do, like exercise or eat less fat).

If history is any guide, we're betting
that when another such study is done in the future, we'll be better
than we are now in some measures and worse in others. And we won't know
why. And we'll say that 'more research is needed'. Cardiovascular
disease rates have risen and fallen over the past 60 years or so, and we
still don't know why -- and that's just one disease. A serious
question is how to deal with phenomena that are so changing, and so
subtly complex, that we have to keep surveying to understand them.
Could there be some better way, a different approach?

---------------------
*Thanks to Bob Ferrell for bringing this to our attention.

8 comments:

Jim Wood
said...

Anne, I do wish there was more equity in the distribution of health care in the US, although as you point out it wouldn't solve the problem. But, whenever I see reports such as the one you point to, I gotta wonder: is it really such a bad thing to be 16th out of the 16 most long-lived, best nourished human populations that have ever existed? See my earlier post on "A view from the Neolithic" or whatever it was called. It's also notable how much of our health "problem" is self-imposed. We eat too much, we smoke too much, we have too much unprotected sex, we drive too fast, we do too much dope. Now I don't want to encourage risky behavior (or come across as a libertarian), but surely at some point we've got to ask how much fun we're willing to curtail in order to achieve marginal improvements in our health statistics. No?

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